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Thursday, July 19, 2018

In Fiduciary I Trust

At least, that's the motto by which they live, right? It's a trustee-beneficiary relationship. 
The beneficiary is trusting the trustee to make sound decisions on her behalf, right? 
Sitting in a prescriber's office, minding my own, when the conversation piqued my interest. (Couldn't help it. She was really quite loud for the quiet space.) 

Fiduciary Lady Opining: I'm your fiduciary. You know what that is? 
Recipient Of FLOs Largesse: No. 
FLO: I make your decisions for you and you trust me. 
ROFL: Ok. That makes sense. 
FLO: I look out for your best interests. 
ROFL: Ok. That's good. 
FLO: You're getting your shots today. 
ROFL: Hooray. Which ones?
FLO: Tetanus, Meningococcal, and . . . wait. Not this one. 
ROFL: Why not? 
FLO: It's HPV. 
ROFL: What's that? 
FLO: A sex disease. It was made for girls. 
ROFL: Uh-huh. 
FLO: For people with vaginas! You don't have a vagina, do you? 
ROFL: HaHa, no. 
FLO: Then you don't need this. They decided they needed more money so they said boys had to have it now too. 
ROFL: But I don't have a vagina. 
FLO: Which is why you're not getting this one. 
Poor Nurse: The doctor will be in shortly. 
FLO: He's not getting the HPV shot. 
PN: No problem. 
FLO: What's the name of it? 
(There was a conversation that went on for 3 minutes as they tried to figure it out and I couldn't take it anymore.) 
CP: GARDASIL!
PN: Thank you. 
FLO: What's this pertussis? I thought he was getting tetanus? 
PN: It's whooping cough. 
FLO: He's not coughing. 
PN: And we'd like to keep it that way. 
<PN leaves>
CP: Psst. 
FLO: Yes? 
CP: I'm talking to your boy too. 
ROFL: What? 
CP: Are you attached to your penis? 
FLO: What? 
ROFL: What? 
CP: How'd ya like warts on your naughty bits? 
<They both cringe>
CP: <holds out phone after googling "genital warts"> Here's what you can look forward to without the vaccine. Have a nice day!
PN: You can come back now, CP. 
CP: Thanks. I think you're going to give that HPV vaccine now. 
PN: Yes. You really need to stop doing that. 
CP: If people are going to loudly announce they're responsible for making decisions for their ward, the least they could do is ask questions in order to make INFORMED decisions instead of propagating IGNORANCE. I'd have no problem with her refusal had it been based on anything other than uninformed, empty rhetoric. 

Thursday, July 5, 2018

Professional Differences

Why are the same laws not applied universally?
If you wish to understand the issue, look no further than any law affecting healthcare in America. States pass new rules/laws all the time. Some affect both prescribers and pharmacists and we must both obey and implement them.
Prior to graduation, I had to take a law class.
Prior to receiving my license, I had to take a law test (and pass it!).
I'm fairly certain prescribers had to do this as well.
In the years since I graduated, laws have changed and new ones have been passed.
This means that your practice has to be fluid in order accommodate these changes.
You cannot simply rely on what you learned in school. You have to evolve; to adjust.

Herein lies the difference between the prescribing and dispensing professions.

Pharmacists: this law takes effect 7/1/18. You MUST be compliant on this date or you shall be publicly flogged, pilloried, or stoned. There are no exceptions for failure to comply. If prescribers do not comply, it is incumbent upon the pharmacist to phone the prescriber to bring him up to speed, retrieve the missing information, and get lectured by the lady answering the phone (LAP).
LAP: What do you need?
CP: As of July 1st, your prescribers must obey these laws.
LAP: Laws? We don't need no stinkin' laws!
CP: You do.
LAP: We didn't know about this.
CP: You work in a urology group, right?
LAP: Yes.
CP: Urine trouble!
LAP: Lame. I've heard that one before.
CP: I know. Just like I've heard what you're about to tell me next.
LAP: 1. We've never had this problem with any other pharmacy.
2. You're the only pharmacist who calls us on this.
3. We never had to do this before.
4. Our prescribers don't do that.
CP: 1. Yes. I know.
2. Yes. I'm the only pharmacist who cares about her license.
3. That's because the law took effect July 1st. There were communiques.
4. They will.

Prescribers: you get an email from the state; you get a letter from the state; you get more of each, approximately 1 per week for 6 months leading up to Doomsday. You get to plead ignorance for months. There's something called a "grace period". For some reason, you are allowed to remain noncompliant and ignorant of the law change for months. You receive more, somewhat-sternly written letters with a picture of the Board of Medicine shaking its finger at you and a little "tsk tsk" added for effect over the next 6 months. Yet you still plead ignorant.

This reminds me of my favourite prescriber joke: 
Q: Why are doctors always on bottom? 
A: Because they can only fuck up!


Thursday, June 28, 2018

Professionally, No

Me: What conversation are we having today?
CP: A major pet peeve among pharmacy staff is when patients ask for refills by telling us to "just fill everything". 
Me: Agreed. Every time you write a post about patients and refills, this has to be the number one complaint. Why don't we like that again? 
CP: First, it's lazy. If you're too lazy to tell me which medications you are taking, too lazy to find the bottles in your house, too lazy to write down the numbers or names of the medication(s) you currently take, I'm too lazy to "just fill everything".
Me: Like you always say, I should not care more about your health than you do. 
CP: Right. 
Me: What else is wrong with the Customer Of the Day (COD) saying "just fill everything"?
CP: We could fill medications the patient no longer takes. We could fill old strengths, old combinations, or duplicate medications within a class. Maybe the patient had a reaction. Maybe a new prescriber changed therapies. Maybe they have some medications filled at another pharmacy in another form. The point is, we could contribute to medication mismanagement by just filling everything. It's our job to make sure their therapy is up-to-date. It's part of the CMR process for this reason. 
Me: In other words, it's professionally irresponsible to "just fill everything". 
CP: Succinctly stated. 
Me: Is there another part to this? 
CP: Yes. If the patient leaves with something they don't take, they'll ask to bring it back. If they don't leave with it, but notice they don't need it before they leave, we will have to put it back. Imagine the work involved if we filled an extra 2 prescriptions for every patient every day then had to return the same extra 2 prescriptions every day. It's not like we have anything better to do than undoing all our work. It's another reason #WhyYourPrescriptionTakesSoLong. 
Me: Got it. I have to ask. Why are we having this conversation? Usually you let people fight it out in the comments section of your posts. You rarely tackle the "just fill them all, let COD sort them out" issue directly. 
CP: The phone call I received recently. 
Me: Go on. 
CP: You agree that pharmacy staff everywhere despise the "just fill everything" mantra, yes? 
Me: Yes. They are very vocal in their opposition to this. 
CP: I received a phone call from a pharmacy to transfer prescriptions. 
Me: Okay. Normal. What's wrong with that? 
CP: I asked "how many" and was told "I'm not sure yet". Cute. But I knew where this was headed. 
Me: Let me guess, the pharmacist said "just fill everything"?
CP: Yes. The pharmacist, who likely loathes the "just fill everything" from his patients, told me the patient requested a transfer of "everything". 
Me: What did you do? 
CP: After madly cackling for nigh on a second then realising he was serious, I said "no". When he seemed stunned, I explained my reasoning. 
Me: You could have just transferred the whole profile. 
CP: True. I could have. In which case, again, I would have been performing needless work for a lazy patient who no longer wanted to be my patient. 
Me: <whispers> I can see why. 
CP: Shut it! Why would I waste my time, and the other pharmacist's time, to transfer prescriptions this feckless COD may not need? How far back do I go in the profile? Do I transfer the coochie cream from 6 months ago? Everything that is on hold and hasn't been filled over the last 6 months just in case the time is ripe to get that Belviq or Cialis filled? 
Me: I get it. What you're saying is pharmacists can't have it both ways. 
CP: Right. You can't complain about how patients act then encourage and engage in that same behaviour with another professional. 
Me: I see your point. 
CP: Thank you. Do you think others will? 
Me: Of course. 
CP: Thanks.
Me: You really need a verbal jousting partner, when CP's Partner isn't here.
CP: Intellectual intercourse? 
Me: Yes. 
CP: It's not my phault they keep cutting hours so I have to work just with you all night. 

Monday, June 25, 2018

Miscarriage of Duty

I have so many problems with this situation. Having been on both sides of the counter for this, I can sympathize with the mother and how poorly it was handled.

1. You're a pharmacist. You understand how these medications work. The woman was carrying a lifeless fetus in her womb. Whatever your personal beliefs about abortion, this is not killing a baby. She is inducing delivery of a deceased fetus. You are no more responsible for its death than the hotelier who gave a couple a room is responsible for them getting pregnant on one of his beds.

2. I know it's a "he said, she said" sort of situation but did the pharmacist really stand at the counter, prescription in hand, and refrain from giving it to her? If so, he's no colleague of mine and I'd be ashamed to call him one. Take her aside to explain it. Allow someone else to sell it to her. Under no circumstances should you explain it's for your own ethical reasons that you are denying the sale. I won't push my beliefs on you, you don't push them on me. That's how this played out in front of other patients. Yes. You are allowed to possess them. Yes. You, in Arizona, are allowed to deny the sale for this reason. However, your lack of empathy is uncalled for and galling. Call a pharmacy down the road and transfer it.

3. I do not agree with these "ethical, moral, religious" exemptions. If I believed the world was flat, I'd not take a job in a globe factory or store. (Is this the best analogy? No. It's lame, but it'll make people think a little about the inanity.) If you don't like vaginas, don't become a gynecologist. You don't get to pick and choose which medications you're going to dispense. An addict is dying in the street. Do you hand a box of Narcan over the counter to help save her and say "come back and we'll bill it later"? Do you hand a bottle of Nitroglycerin over to the wife of a man who is having chest pains out front? Definitely. Do you allow your beliefs to get in the way of saving someone's life? You cannot if you have any ethics at all.

4. When I was in my Ethics class in school, we had to watch these cheesy vignettes and determine if they were ethical responses from the pharmacist. The only one I remember was a man filling Estrogen for himself on his way to becoming a woman. The pharmacist looked at him and went "WHOA! NO way!" and handed it back. At the time, I remembered the Stone Temple Pilots song, Creep, and I said "It's not our decision. We have to let him become half the man he used to be". It's a legitimate prescription for a legitimate reason. While we may not agree with the intended use, there is nothing ethically wrong with it.

which leads me to. . .

5. "Arteaga filed a complaint with the Arizona State Board of Pharmacy. And, she wants a law in place that would require pharmacies to fill prescriptions approved by doctors." 
Whole buncha NOPE NOPE NOPE on this one. (If anyone wants to know why this is a bad idea, see "Opioid Crisis in America" and you'll learn what happens in these cases.) We are professionals. We are trained to use professional judgement. While I sympathize with her in this ordeal, there is no way in hell I am going to be a prescribers' bitch and fill whatever they write. That is not the job of the pharmacist. I can see it now:
"Sorry ma'am. Your prescriber is trying to kill you with this drug interaction but the law says I have to give it you and not question his almighty-ness."

To me this means she, like most of the general public, does not understand a damn thing about what our job is. We are more than just "pouring pills from big bottles into little bottles, label slapping, mindless automatons". When the social media outrage over this subsides, we will back in the shadows, doing our jobs of making sure your prescribers don't kill you. That you take the correct medications correctly.

Now that I think about it, I'm Batman.

https://www.khou.com/article/news/nation-world/walgreens-pharmacist-denies-pregnant-woman-miscarriage-medication-over-his-ethical-beliefs

Wednesday, June 20, 2018

Stop Messing Around

Bottle Looks Unfamiliar: You gave me the wrong medication.
CP: And Good Morning to you too.
BLU: Are you trying to kill me?
CP: I don't even know you. So, not yet. But keep it up and. . .
BLU: You gave me blue tablets.
CP: Okay. Are they making you sad because they're blue?
BLU: What? No! They're not working.
CP: That's hardly an attempt on your life.
BLU: I called my doctor and he said you must have given me a cheaper version.
CP: Well, he IS a doctor who does not work in my pharmacy so his expertise is unquestionable in this.
BLU: You're messing with people's lives here!
CP: Yes. Pharmacies are now conducting social experiments. How will patients respond if we switch from red to blue?
BLU: The green ones worked that I got last month! And the Nitroglycerin you gave me are not round like the ones I've been getting at CVS. I haven't slept in a week!
CP: So you had been getting your prescriptions at CVS and now you switched to me and because I dispensed a different manufacturer, I am messing with your life?
BLU: Yes.
CP: Curious line of thinking. Colour does not equal potency. I also could not explain to you that the colour had changed since I did not know what you received last month. You do have to expect that if you change pharmacies, other things will be different as well. I mean, the pharmacist was different too. Or did you not notice that?
BLU: But the colour is different and my doctor said you gave me cheaper stuff.
CP: Yes. Your doctor. Who knows less than nothing about what I do. Did you know your doctor buys his flu shots at the end of the purchasing season, after all the pharmacies? Know why? because he wants the cheapest stuff around. So make sure you don't get your flu shot from your doctor because he gives cheaper versions. His flu shots are probably blue too.
BLU: You don't know that.
CP: Any more than your doctor knows what I do.

Patients?

Someone asked me to answer the question of pharmacy visitors should be called: Patients or Customers. Simply put, here is my response. 

Patient: A person receiving or registered to receive medical treatment. (Yes)

Treatment: Medical care given to a patient for an illness or injury. (Yes)

Care: The provision of what is necessary for the health, welfare, maintenance, and protection of someone or something. (Yes)

Provision: The action of providing or supplying something for use. (Yes)

Customer: A person who buys goods or services from a shop or business. (No)

Goods: Merchandise or possessions. (No) 

Regardless of practise location, pharmacy visitors are patients. 

OTC as Rx?

I received a fax back from a prescriber's office last week with this note:
"Stop sending prior auth requests for meds patients can buy OTC."

To which I promptly replied:
"Stop sending Rxs for items patients can buy OTC."

The question often arises on pharmacy phorums about OTC products being prescribed and filled as prescriptions and a lengthy, often heated debate ensues. I often wonder why. Here is a discussion I recently had with myself playing Devil's Advocate with. . . well, myself.

CP: We get paid to fill prescriptions.
Me: But they're a pain in the ass.
CP: How, exactly?
Me: They're not in the computer.
CP: When was the last time we dispensed something that wasn't in the computer?
Me: I don't know. That's the typical counter argument.
CP: I can find an NDC made by Major or Rugby for almost every medication prescribed in our area.
Me: But they're not covered.
CP: Sure they are. Most Medicaid plans cover those NDCs in particular. Most commercial insurances do not, but I have had a few Medicare D plans pay as well.
Me: They're more expensive than the patient buying it OTC.
CP: Match the price.
Me: Too much work.
CP: Why?
Me: They. Can. Buy. It. O. T. C. and not bother me.
CP: They can. Maybe they don't need the whole box which will go to waste. Also, if we fill it as a prescription, it will have a label on it. The label will clearly instruct the patient how the prescriber wanted them to take it which may differ from the OTC package directions. In a week or a month when the patient has to take it again, where will the directions be? Which will they follow?
Me: They will have kept the instructions in the package, right?
CP: Sure. And I'm Batman.
Me: But we don't make money off them.
CP: Really? That's your argument?  We are the better profession. We are the last line in making sure our patients take their medications correctly. When was the last time you had to do an MTM and the patient remembered every OTC item they were taking? If we fill them as Rxs, we have them on file. We can run drug interactions against the other medications we are filling. Why would we not fill these as prescriptions?
Me: The patients won't pay for them.
CP: The patients who have FSA accounts will be happy to pay for them. Many plans will only allow their funds to go towards Rx items. If they walk up with a box of Pepcid, their card will not allow the purchase. They may be able to submit the receipt, but this is easier for them. Also, they can bypass the Pseudoephedrine limits and get a whole month of Claritin-D or Allegra-D if we fill it as a prescription.
Me: What about supplies?
CP: What about them? We already bill Glucose meters, test strips, lancets, alcohol pads, syringes, and pen needles on prescriptions. How would a nebulizer be any different? We do those too. Once you find an NDC that works, order it. Bill it. Fill it.
Me: Crutches?
CP: I have.
Me: So there are a lot of items we could bill?
CP: Yes. The vast majority of OTC prescriptions we fill are for former or current Rx items (Ibuprofen, APAP, ASA, Pepcid, Zantac, Prilosec, Flonase) and Mucinex, Delsym, Benadryl, eye drops, ear drops, etc. All you have to do is find one once and keep it on the shelf. Our job is to provide healthcare. I fail to see how telling people to buy something OTC when we received it as a prescription is doing our job.

Remember:
Some insurances pay for OTC items. If not, override the price.
The patients will have the correct instructions.
The patient doesn't have to purchase a whole box if they only need a week supply.
FSAs will pay for OTCs as Rx items.
We will have a more complete medication history for interactions.
Patients will be happy.
It's no more work than any Rx item you're already filling.
We get paid to fill prescriptions. (ps these count as prescriptions too.)

As for my note at the top, I knew the patient's insurance would cover the medication with a PA which is why I faxed it initially. We filled it on a discount card for less than OTC and the patient was happy.

Thursday, June 14, 2018

Kiwis

I had this already written but hadn't decided when to post it. When I received the e-script, it made the post that much better.
CP: I'm calling to get the patient's e-script changed from Humalog vials to Humalog Kwik Pens.
Nurse: Okay. You want the Kiwi Pens?
CP: No. I want Kwik Pens.
Nurse: The Kiwi Pens?
CP: You do work in an endocrinologist's office, right?
Nurse: Yes.
CP: They're called Kwik Pens. Not Kiwis. Can you just send me a new prescription for the Humalog KWIK Pens so we don't have to go through this every month.
Nurse: I'll ask the doctor about Kiwi Pens.
CP: If he doesn't explain to you they're Kwik Pens, I'll come over and kick him in the kiwis.
Nurse: He said it's okay to give him Kiwi Pens.
CP: Is that the punchline to a really lame joke? 
What do New Zealanders write with? Kiwi Pens?
Nurse: Um. . . No? Anything else? 
CP: Yes We need pen needles so the patient can inject Kiwis. 
Nurse. Okay. I'll send those over shortly. 
CP: I can't wait to see what I get. 

<later> 




CP: Wikipedia? WTAF?